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1 Oregon Occupational Therapy Licensing Board State Office Building, 800 NE Oregon St., Suite 407 Portland, OR Phone: FAX: Felicia Holgate, Director For Office Use Only: Revenue Code 0210 License Application Fee $25 LIMITED PERMIT Payment made on by check LICENSE APPLICATION OCCUPATIONAL THERAPY or OCCUPATIONAL THERAPY ASSISTANT Return signed, complete form with $25 check or money order payable to the OT Licensing Board. Have school transcripts sent directly to the Oregon OT Licensing Board. Send copy of your Authorization to Test letter from NBCOT (forward or faxed copy is sufficient). the OTLB your scheduled exam date so they can verify your score online following the exam. Have signed Statement of Supervision filed in the OTLB office prior to working under the LP. LP License Expires 90 days from date of NBCOT Eligibility to Test Letter 1. FIRST NAME PERSONAL INFORMATION MI LAST NAME Other names used: Male Female 2. PREFERRED MAIL ADDRESS HOME WORK te: Correspondence will be mailed to preferred address. SOCIAL SECURITY NO. See Privacy tification BIRTH DATE 3. HOME ADDRESS (MAILING: STREET OR PO BOX) HM. PHONE 4. CITY Home STATE HM. ZIP 5. ADDRESS (We save $ by use of ; we do not give it out unless required by law; please keep it updated) COLLEGE / UNIVERSITY WHERE OT DEGREE RECEIVED EDUCATION CITY / STATE DEGREE AREA OF STUDY GRADUATION DATE LICENSURE & HISTORY INFORMATION Have you signed up to take the National Certification Exam? Indicate date: Have you received and included your Eligibility to Test letter from NBCOT? If not, when do you plan to take exam: I certify that everything in this application form is true and correct, cognizant that any falsification could result in denial, suspension, and/or revocation of my permit/license. I am aware that a license must be issued and approved prior to practicing Occupational Therapy in Oregon. Signature: Date: BE SURE TO FILL OUT AND ENCLOSE REGULAR APPLICATION FORM WHICH FOLLOWS OTLB Limited Permit OT APPLICATION FORM PAGE 1

2 Oregon Occupational Therapy Licensing Board State Office Building, 800 NE Oregon St., Suite 407 Portland, OR Phone: FAX: Felicia Holgate, Director LICENSE APPLICATION for OCCUPATIONAL THERAPY or OT Assistant For office Use only: Payment made on by check BE SURE TO FILL OUT THIS REGULAR APPLICATION FORM AND INCLUDE IT WITH THE LP FORM Fee for OT license is $100 for 1 year license, expires May 31, Fee for OT Assistant license is $70 for 1 year license, expires May 31, Return signed, completed form. Send fee (either for OT or OT Assistant ) payable to the OT Licensing Board. Have school transcripts for all newly licensed applicants sent to the Oregon Board. the OTLB your scheduled exam date so they can verify your score online following the exam. License Expires May 31, 2016 PERSONAL INFORMATION 1. FIRST NAME MI LAST NAME Male Female 2. PREFERRED MAIL ADDRESS HOME WORK te: Correspondence will be mailed to preferred address. SOCIAL SECURITY NO. See Privacy tification BIRTH DATE 3. HOME ADDRESS (MAILING: STREET OR PO BOX) HM. PHONE 4. CITY Home STATE HM. ZIP 5. ADDRESS (We save costs by use of ; we do not give it out unless required by law; please keep it updated) EMPLOYMENT INFORMATION 6. FACILITY POSITION 7. WK. ADDRESS (MAILING: STREET OR PO BOX) WK. PHONE 8. WK. CITY WK. STATE WK. ZIP EDUCATION 9. COLLEGE / UNIVERSITY WHERE OT DEGREE RECEIVED CITY / STATE 10. DEGREE AREA OF STUDY GRADUATION DATE OTLB Limited Permit OT APPLICATION FORM PAGE 2

3 BACKGROUND QUESTIONS Please answer each question by putting a check in the appropriate box. You must answer each question with a or response. If you answer, provide a detailed explanation on a separate sheet of paper of the circumstances, include relevant dates, jurisdiction and/or parties involved, and sign and date the page. 11. Have you ever been cited, arrested, charged with or convicted of a crime, offence or violation of law in any state or by the Federal Government even if those charges were dismissed? 12. Have you ever been the subject of a complaint or lawsuit regarding your Occupational Therapy or any other professional practice? 13. Are there any unresolved or pending actions or complaints against you with any professional licensing or certifying authority? 14 Have you ever voluntarily surrendered any license or certification? 15. Have you ever been sanctioned by a professional licensing or certifying authority? 16. Have you ever had limitations or restrictions placed on a professional license or certification? 17. Do you have any condition that in any way impairs or may impair your capacity to perform duties of an Occupational Therapist with reasonable skill and safety? SPECIALTY AREAS Please check your area(s) of practice Developmental Disability Education Geriatric Hand Home Health Mental Health Pediatric Physical Disability Private Practice Rehabilitation Sensory Integration Other PROFICIENCY IN LANGUAGES OTHER THAN ENGLISH Please check Bilingual? Spoken? Written? Fluent? American Sign Language Arabic Farsi French Hmong German Japanese Korean Mandarin Romanian Russian Spanish Tagalog Vietnamese Other RACE and ETHNICITY RACE (Select one): American or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White / Caucasian Other (Multi-Ethnic) Decline to Answer ETHNICITY (Select one): Hispanic or Latino t Hispanic or Latino Decline to Answer OTLB Limited Permit OT APPLICATION FORM PAGE 3

4 PRIVACY ACT NOTIFICATION: Use of Social Security Number Under Oregon and Federal law ORS and 42 USC 666(a)(13), the Occupational Therapy Licensing Board is authorized to obtain your Social Security Number for identification and legal purposes in maintaining records, obtaining grades and exam scores, child support enforcement, federal and state tax administration, reporting final disciplinary actions to the Health Integrity and Protection Data Bank, and verifying disciplinary or criminal background. Failure to provide your Social Security Number can be a basis for the OT Licensing Board to refuse to issue, renew, or reinstate the license. Your Social Security Number will be kept confidential by the Board and used only for the purposes described above. SIGNATURE OF APPLICANT I agree to obey the laws, rules and regulations of the Oregon Occupational Therapy Licensing Board and to maintain the honor and dignity of the profession. I understand and agree that my license may be suspended or revoked by the Board at any time if I have made any false statements in this application or provided any false information, which resulted in the approval of my license application. I hereby certify that I am able to competently and safely perform the essential functions and duties of an Occupational Therapist. I hereby declare that the information in this application, including any and all attachments, is true to the best of my knowledge and belief, and that I understand it is subject to penalty for perjury. Applicant Signature Date Return Application, fee & documents to: OT Licensing Board 800 NE OREGON ST., # 407 Portland, OR OTLB Limited Permit OT APPLICATION FORM PAGE 4

5 TO THE SUPERVISOR OF THE LIMITED PERMIT HOLDER For OT _&_For OT Assistant 1. Please complete this section by printing legibly. Please provide the full name of the employing agency. 2. The supervisor certifies that the permittee will be employed and work under the supervision of an Oregon-licensed occupational therapist and that the expiration date of the limited permit will be noted and observed. 3. The limited permit is valid only until the Board receives results of the certification the exams. Should the Limited Permit Holder Fail the Certification Exam, the Limited Permit Immediately Is Void and Must Be Surrendered upon Receipt Of Exam Scores. The Limited Permit Cannot Be Renewed. 4. Limited permit holders require at least routine supervision (direct contact at least every two weeks at the work site with interim supervision occurring by other methods, such as telephone or written communication). I certify that I will provide supervision as defined in OAR (1)(b) for the limited permit holder named: OAR (1) states that "Supervision" is a process in which two or more people participate in a joint effort to promote, establish, maintain and/or evaluate a level of performance. The occupational therapist is responsible for the program outcomes and documentation to accomplish the goals and objectives. OT/OA Limited Permit applicant Information Print Name of Applicant Print Name of Supervising OT Supervisor Information Date Supervision To Begin Signature & License. Of Supervising OT Employer s Name Telephone Applicant OT Employer s Address After this Statement of Supervision form has been completed, please mail it either with your Limited Permit Application, or separately, to: Occupational Therapy Licensing Board Suite 407, 800 NE Oregon, Portland, OR Telephone: (971) Fax: (971) OTLB Limited Permit OT APPLICATION FORM PAGE 5

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